IBA ‘mystery shopping’ experiences: the good, the bad and the…

12 Sep

Recently I posted about opportunities to ‘mystery shop’ IBA when signing up to new GP practice. Whilst there are some issues to consider, generally I think this can be a really valuable way to make a difference. As we seem to know IBA is often poorly delivered in Primary Care, so we need to take every opportunity we can to help improve it.

So here is summary of some of my three actual ‘mystery shopping’ experiences, which interestingly ranged from good to bad. And something in-between…

The good…

At the risk of being unfair, I will probably skip through the good one. There’s not a lot to learn from it, other than as proof that IBA in Primary Care can be done well, and it’s not a lot to expect.

Essentially after I had registered at a large surgery in London a practice nurse asked me some questions about my alcohol use at the initial health check. After a positive AUDIT score, she talked through some simple advice around units and asked if I had any questions. It wasn’t perfect (I don’t recall getting a leaflet) but I’m pretty sure it ticked enough of the boxes to count as effective IBA. Great!

The bad…

In truth, bad is putting it kindly. Here’s what happened. I registered with a new practice and was given a series of forms to complete. This included a barely readable photocopy of the FAST and AUDIT screening tools. The FAST asked ‘how often did I have 8 or more “standard drinks”, without any description of a standard drink. A standard drink in this case is supposed to be the equivalent to one unit. So by assuming a standard drink is a pint of Stella, I would underestimate my consumption by two-thirds. That’s a lot of risky drinkers who will wrongly score as lower risk. A payment is still picked up.

So I filled in FAST and AUDIT as if I was back in my student days and handed it in. I was next advised I would need to see a practice nurse to run through some things, so I duly returned for an appointment. It was mianly about booking appointments and some other process stuff – no health check stuff. At the end I asked about the alcohol scores I had completed. “Oh, your GP will talk to you about those if its a problem.” Hmm.

Anyway, I booked an appointment for a genuine health concern of lower back pain. The GP was helpful, in no hurry and explained the referral to a physio and what to expect. But nothing about the alcohol. So I asked again. Here’s where it fell apart. “The practice nurse should talk to you about that”. “She said you would”, I politely informed the GP. “Well, I don’t know what these scores mean” he said after looking up my scores electronically. At least they’d been recorded I suppose.

At this point I came clean. Not too surprisingly, the GP went on the defensive, then picked up the phone to a nurse and said “someone in here needs and alcohol leaflet”. I could see they were on the back foot, so I decided I would take it up with the practice manager.

In the end I contacted the local commissioner and subsequently the practice did arrange for a 30 minute slot for an explanation of IBA and what they should be doing at a team meeting. They could have done with a proper training session, but they have apparently stopped handing out screening tools and the practice nurse now goes through it. It would certainly be interesting to re-register and see how its going!

The mixed…

My most recent experience wasn’t great, but certainly the practice was trying! The initial registration forms asked ‘How many drinks per week’, to which I thought an answer of 20 should be enough to trigger the next stage. Again, I was asked to arrange to see a practice nurse, who duly talked through my answers. “You don’t smoke – good”. Next question. “Alcohol, OK, so you drink 20 drinks per week on average?” “Yes”. “Right, OK that’s around 20 units per week, which is within the government guidelines of 21 for men”..

Spot the fatal error? I hope so. So I questioned whether some drinks could have more than 1 unit of alcohol. “It depends, err… let’s have a look” the nurse said, pulling out a photocopied units poster. “Ah, so you’re drinking 20 pints, yes that could be more, ohh, double, oh that’s not good!”. Sigh!

At this point things did begin to improve though. I was told that she was supposed to go though an alcohol questionnaire anyway, so again I duly filled in the FAST then AUDIT. The nurse managed to total up the correct scores after a little confusion, and inform me I was a “hazardous drinker”. I wasn’t allowed any time to ponder it (contemplation is key), but instead was read a list of health problems – “depression, anxiety, stress, impotence…”. I asked slightly mockingly whether I had all of those, and was rightly told they were possible risk factors of hazardous drinking. “These are just to get you thinking”. I rather liked that, though of course I would have rather heard “How do you feel about that?” or “Can you think of any benefits to cutting down?”. Nonetheless I was given lots of information, including recognised IBA resources to take away.

To be fair, it seemed clear the practice nurse had not received any training in IBA, so was following a process. How much better would it have been if she’d had a few hours to explore IBA skills and understand the importance of allowing contemplation in the drinker? Nonetheless, I was ‘identified’ and given feedback, which is still likely to get some people thinking as the key to IBA.


From my tiny snapshot of ‘mystery shops’ we can clearly see the picture of IBA delivery in Primary Care is mixed, and there is a lot to improve on. Practices need to have the right processes in place, the right tools available, but crucially staff need the knowledge and skills to have such conversations. Practices need to take on responsibility for this, especially where they are receiving payments. Local commissioners must ensure practices can access the support they need, and hold to account those that are not doing things they way they should. Finally, the DES national incentive system has clearly had an impact in instigating IBA, but clearly it seems more development or stronger levers are needed. Whether or not you have a responsibility to quality check IBA in your own practice by ‘mystery shopping’, well I’ll leave that for you to decide!

One Response to “IBA ‘mystery shopping’ experiences: the good, the bad and the…”

  1. Tiffany September 13, 2012 at 9:11 am #

    Not surprising, and certainly backed up by our recent focus groups with 65+ as to the patchy quality of advice given out to problem drinkers in a primary care setting.

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